Surgical treatment of unruptured cerebral aneurysms in the elderly.

We retrospectively analyzed the prevalence and surgical outcomes of unruptured cerebral aneurysms in the elderly for the past five years. Between 1998 and 2002, we collected data from 575 subjects with unruptured aneurysms who had no history of subarachnoid hemorrhage (SAH). One hundred and eighty-two of these patients (31.7%) were aged > or = 70 years and they had 233 aneurysms. The proportion of older patients among all subjects increased significantly from 21.4% in 1998 to 40.3% in 2002. Unruptured aneurysms found in the elderly had a predominance of female, higher frequency of multiple aneurysms, and lower frequency of anterior communicating artery aneurysms when compared with those in the younger patients. The majority of intradural aneurysms detected in the elderly were less than 10 mm in diameter (84.8%). One hundred and eleven out of 224 intradural aneurysms in the elderly were treated (49.6%); most aneurysms were directly clipped, while only 13 aneurysms including six basilar artery aneurysms were coiled endovascularly. Among the 83 elderly subjects who underwent direct surgery, perioperative complication appeared in seven subjects (morbidity 8.4%, mortality 1.2%). No SAH occurred postoperatively and conservatively during 1-5 years of follow-up. Since the rupture rate of small unruptured aneurysms without SAH history is reported to be low, surgical indication should be considered with care particularly in the elderly.

Treatment of unruptured cerebral aneurysms; a multi-center study at Japanese national hospitals.

The treatment and natural course of unruptured cerebral aneurysms were analyzed in 615 patients with 712 unruptured cerebral aneurysms registered from seven Japanese national hospitals and Zurich University hospital. For 209 aneurysms in 181 cases, the natural course of the aneurysms was observed without surgical treatment. During the follow-up period of 3,862 months (321.8 years), 11 of these aneurysms ruptured giving a rupture rate of 3.42%/year. Five of these 11 aneurysms were less than 10 mm in diameter. Seventeen aneurysms of these 209 untreated aneurysms had blebs. Seven of these 17 aneurysms ruptured yielding the high rupture rate of 28.3%/year. The likelihood of unruptured cerebral aneurysms to rupture was not exceedingly low even when the aneurysms were smaller than 10 mm. Since the risk of rupture and morbidity in relation to surgical treatment cannot be predicted by size alone, the morphology, especially the presence of blebs, should be considered when treating unruptured cerebral aneurysms. In 434 patients, 503 cerebral aneurysms were treated surgically either by craniotomy in 472 aneurysms or endovascular coil embolization in 31 aneurysms. Surgical outcome was influenced by the presence of concurrent diseases, patient age, size and location of the aneurysms. Complications after surgical treatment of 128 incidentally found aneurysms were reported in four cases; three cases of hemiparesis and one case showing disturbance of higher brain function, with a morbidity rate of 3.1%. These results suggest that surgical treatment may be acceptable in cases of incidentally found cerebral aneurysms, especially when blebs are present.

Brain proton magnetic resonance spectroscopy in children exposed to methamphetamine in utero.

OBJECTIVE: To examine the possible neurotoxic effects of prenatal methamphetamine exposure on the developing brain using 1H-MRS. METHODS: Methamphetamine-exposed children (n = 12) and age-matched unexposed control subjects (n = 14) were evaluated with MRI, localized 1H-MRS, and a Child Behavior Checklist. Metabolite concentrations of N-acetyl-containing compounds (NA), total creatine (Cr), choline-containing compounds, myoinositol, and glutamate + glutamine were measured in the frontal white matter and striatum. RESULTS: Despite an absence of visible structural abnormalities in either group, children exposed to methamphetamine in utero had higher [Cr] (+10%, p = 0.02) in the striatum. [NA], primarily a measure of N-acetylaspartate, was normal in both regions, which suggests no significant neuronal loss or damage in the two brain regions examined. There were no differences in reported behavior problems among the methamphetamine-exposed children relative to the unexposed group. CONCLUSIONS: The authors found increased [Cr] in the striatum with relatively normal [NA] in children exposed to methamphetamine. These findings suggest an abnormality in energy metabolism in the brains of children exposed to methamphetamine in utero.

Risk factors for postcesarean endomyometritis.

Postcesarean endomyometritis is the most common nosocomial infection treated by obstetrician-gynecologists. One important prevention strategy is the use of perioperative antibiotic prophylaxis initiated after occlusion of the umbilical cord for parturient patients with a high risk of this infection. However, the identification of these high risk patients remains problematic. Numerous clinical risk factors have been identified in the literature. Important intrinsic risk factors include indigent socioeconomic status, anemia, and preterm gestational age at the time of cesarean section. The three most consistently identified extrinsic risk factors include labor prior to cesarean section, the duration of ruptured chorioamniotic membranes, and the number of preoperative vaginal examinations. Alternatively, many investigators have attempted to define high-risk patients utilizing various laboratory tests, such as Gram staining or bacterial culture of amniotic fluid, chorioamniotic membranes, or endometrial biopsy specimens; although specific, these tests have not been sufficiently sensitive predictors of infection. Currently, assessment of the duration of ruptured membranes and length of labor remain the most sensitive, readily available, and therefore clinically useful predictors of postcesarean endomyometritis.

Epidemic perinatal listeriosis at autopsy.

Seven cases of listeriosis identified at perinatal autopsy are described. The cases occurred during the time of a 1985 Los Angeles, California, epidemic of listeriosis from suspected food contamination by Listeria monocytogenes. In only one of seven cases were gross pathologic lesions encountered. Microscopic lesions in six cases consisted of rare, localized microabscesses or granuloma-like lesions in multiple organs and contained histiocytes, monocytes, lymphocytes, and polymorphonuclear leukocytes with variable necrosis. One case had no gross or microscopic findings. Organomegaly was uncommon. The diagnosis was confirmed in three cases by postmortem blood culture. Complete perinatal autopsy is important for confirmation of listeriosis when microbiologic, gross, or microscopic findings alone may not yield characteristic features.

Clinical manifestations of epidemic neonatal listeriosis.

We report the broad spectrum of clinical manifestations in 23 infants with positive cultures for Listeria monocytogenes who were treated in our hospital during a recent epidemic. The majority of infants (70%) were preterm and none was small for gestational age. Thirteen (56%) had respiratory distress at birth with evidence of congenital pneumonia. Four of the 5 deaths occurred among these infants. Four infants considered healthy after resuscitation developed fever and lethargy within 36 hours after birth. Only one of these infants had evidence of pneumonia. We conclude that congenital pneumonia with respiratory distress at birth is the major cause of mortality and morbidity from L. monocytogenes infection in the neonate.

Perinatal listeriosis (early-onset): correlation of antenatal manifestations and neonatal outcome.

Listeria monocytogenes is an underdiagnosed and underreported cause of congenital sepsis. Twenty mother/infant pairs from whom Listeria was isolated were studied at the University of Southern California School of Medicine and Women's Hospital during the last ten years to delineate antepartum factors indicative of a fetus at high risk for perinatal Listeria sepsis. The combination of high maternal leukocyte count, fetal tachycardia, decreased fetal heart rate variability, and, especially, the absence of intrapartum fetal heart rate accelerations was associated with a complicated course for the neonate with congenital Listeria sepsis. Intrapartum administration of antibiotics decreased fetal morbidity and mortality but did not impair recovery of the organism.

Cervical ripening with prostaglandin E2 vaginal suppositories.

A prospective, randomized, double-blind, placebo-controlled study was undertaken to evaluate the safety and efficacy of a 3-mg prostaglandin E2 (PGE2) vaginal suppository for the initiation of cervical ripening before the induction of labor. All patients were required to have an initial Bishop score of 4 or les. The 3-mg PGE2 vaginal suppository was found to be an effective method of both cervical ripening and labor induction. Its use resulted in a highly significant improvement in the mean Bishop score compared with the placebo group (2.67 versus 0.55 points, P less than .00005). Its use also resulted in a significant reduction in the number of failed inductions (5 versus 23%, P less than .0005). Moreover, 68% of the patients treated with PGE2 labored after initial suppository placement, and 42% of these patients never required oxytocin augmentation of labor. However, there were three instances of uterine hyperstimulation/hypertonus following placement of the 3-mg PGE2 suppository, suggesting that perhaps a lower dose of PGE2 would improve its safety as a ripening agent without affecting its efficacy.

Induction of labor with prostaglandin E2 vaginal suppositories.

A prospective randomized study of 85 parturients was undertaken comparing the safety and efficacy of a 3-mg prostaglandin E2 vaginal suppository with intravenous oxytocin for the induction of labor. All patients were required to have a Bishop's score of 5 or higher. Labor was successfully induced in 98% of the patients in both groups by their respective methods. Sixty-four percent of the patients receiving a 3-mg prostaglandin E2 suppository required no intravenous oxytocin. More specifically, 82% (23/28) of the parous patients but only 29% (5/17) of the nulliparous patients who received a single 3-mg prostaglandin E2 suppository for labor induction did not require oxytocin augmentation (P less than .005). The first and second stages of labor were not significantly different for the two groups, and there was no significant difference in the incidence of cesarean section. A 3-mg prostaglandin E2 vaginal suppository may be a useful alternative to oxytocin for the induction of labor in carefully selected patients.

Bacteremia in post-Cesarean section endomyometritis: differential response to therapy.

Presented are blood culture results obtained from 200 patients with post-cesarean section endomyometritis treated with either penicillin-gentamicin or clindamycin-gentamicin. Their clinical course is correlated to their blood culture results by the fever index. Fifty-three percent of the 60 organisms isolated from 48 patients were anaerobic bacteria. Patients from whose blood cultures anaerobic bacteria were recovered had higher fever indexes than did those with aerobic isolates (P less than .05). Clindamycin-gentamicin patients from whose blood cultures anaerobic organisms were isolated had less febrile morbidity than did comparable penicillin-gentamicin patients. Patients with Bacteroides fragilis bacteremia had the highest fever indexes overall. Therefore, patients with post-cesarean section endomyometritis have less febrile morbidity if they are initially treated with a drug effective against anaerobic bacteria, especially B fragilis.

Human immunodeficiency virus-1 seroprevalence among parturients in Los Angeles County public hospitals.

To estimate the prevalence of human immunodeficiency virus type 1 (HIV-1) among parturients in an area with a high cumulative incidence of AIDS, an HIV seroprevalence study was conducted in 1988 in Los Angeles County. Test results were available from 8485 (86.1%) of the 9860 women delivering at four public hospitals. The test results were linked to demographic and medical information available from routinely collected delivery records. Three specimens were HIV-positive, for a seroprevalence of 3.5 per 10,000. The seropositive women were all Latina. The prevalence of HIV among women delivering at all hospitals in Los Angeles County has been shown to be relatively low compared with that of other metropolitan areas with a high number of AIDS cases, such as New York city, but appears to be even lower among women delivering at public hospitals during this time period. This low prevalence is attributed to the predominance of Latinas, who may have lower levels of infection, among public hospital parturients. The relatively low prevalence of HIV among injection drug users in Los Angeles County may contribute to the overall lower prevalence among women in Los Angeles County compared with those in New York city. This study supplements county-specific data obtained from statewide blinded neonatal testing by providing details on HIV seroprevalence among the catchment populations of public hospitals in Los Angeles County.

An intravaginal controlled-release prostaglandin E2 pessary for cervical ripening and initiation of labor at term.

The purpose of this randomized, double-blind study was to evaluate the efficacy and safety of a new controlled-release hydrogel pessary for ripening the cervix and initiating labor. Subjects had an entry Bishop score of 4 or less and gestational age of 37 or more weeks. One hundred fourteen women received a placebo pessary and 101 received the hydrogel pessary, containing 10 mg of prostaglandin (PG) E2. Compared with the placebo group, those given the PGE2 pessary were more likely to have an increase in Bishop score of 3 or more (60 or 59% versus 21 or 18%; P less than .0001), change to a Bishop score of 6 or higher (59 or 58% versus 18 or 16%; P less than .0001), and active labor (68 or 67% versus 15 or 13%; P less than .0001). Including the crossover study, uterine hyperstimulation (28 of 182, 15%) and fetal heart rate abnormalities (18 of 182, 10%) in PGE2-treated subjects were reversed on removal of the pessary with no apparent harm to the mother or fetus. These temporary adverse effects appeared while the pessary was in place and after the onset of active labor. Oxytocin was unnecessary in 89 of 182 (49%) of the PGE2-treated cases and was used more often to augment than to induce labor. We conclude that the described controlled-release PGE2 vaginal pessary induces appreciable cervical ripening and frequently initiates active labor with little or no need for oxytocin. The pessary may cause uterine hyperstimulation or fetal heart rate abnormalities, but these would be expected to reverse on removal of the pessary.

Malonate decarboxylase of Pseudomonas putida is composed of five subunits.

Two different forms of malonate decarboxylase were purified from Pseudomonas putida. The active form was composed of the five different subunits alpha (60 kDa), beta (33 kDa), gamma (28 kDa), delta (13 kDa), and epsilon (30 kDa) and the inactive form was composed of the four subunits lacking the epsilon subunit. The former catalyzed the decarboxylation of malonate to acetate, but the latter could not, although it retained both activities of acetyl-CoA:malonate CoA transferase and malonyl-CoA decarboxylase. The delta subunit of the active form was acylated by the incubation with [2-14C]malonyl-CoA, but the delta subunit of the inactive form was not labeled. From the above results and the N-terminal amino acid sequence analysis, it was concluded that the epsilon subunit was an essential subunit to function as malonyl-CoA:ACP transacylase, which was an indispensable component of the enzyme for the cyclic decarboxylation of malonate.

Serologic evidence of prior chlamydial infection in patients with tubal ectopic pregnancy and contralateral tubal disease.

Oviductal damage from infectious salpingitis is a principle cause of ectopic pregnancy. To examine the role of Chlamydia trachomatis in patients with ectopic pregnancy, 24 patients undergoing laparotomy for ectopic pregnancy were evaluated by assessment of chlamydial serology and chlamydial cultures of tubal biopsy specimens. The patients were divided into two groups based on the presence or absence of gross abnormalities in the fallopian tube contralateral to the ectopic gestation. Ten patients in group I showed gross evidence of chronic salpingitis in the contralateral tube; 14 patients in group II had normal-appearing contralateral tubes. Chlamydial cultures were negative in both groups. Chlamydial immunoglobulin M antibodies assayed by indirect microimmunofluorescence were negative in both groups (less than or equal to 1:32). Mean geometric immunoglobulin G titers for C. trachomatis were significantly higher in the patients with evidence of contralateral chronic salpingitis (78.9 versus 13.1). These findings suggest that C. trachomatis may be a major cause of oviductal damage, which predisposes to ectopic pregnancy.

Chlamydia trachomatis is not an important cause of abnormal postcoital tests in ovulating patients.

To examine the role of Chlamydia trachomatis infections of the cervix and abnormal postcoital tests (PCT) in a general infertility clinic, 63 consecutive patients undergoing a midcycle PCT during a routine infertility workup underwent endocervical curettage, and a 10-ml blood sample was obtained. The endocervical tissue was cultured for C. trachomatis; the serum sample was analyzed for chlamydial IgG and IgM antibodies using an indirect microimmunofluorescence assay. A negative titer was considered to be less than or equal to 1:8 dilution for IgG antibodies and less than or equal to 1:32 dilution for IgM antibodies. A good PCT was defined as greater than or equal to 5 motile sperm per high power field (HPF). A poor PCT was defined as less than 2 motile sperm/HPF, and a fair PCT was defined as 2 to 4 motile sperm/HPF. Of the 63 PCTs done, 27 (42.9%) were good, 14 (22.2%) were fair, and 22 (34.9%) were poor. All endocervical tissue cultures for C. trachomatis obtained during PCTs were negative. All IgM chlamydial antibody titers were negative (less than or equal to 1:32 dilution), 55 (87.3%) of the patients having a zero titer. Eleven (17.5%) of the patients had negative IgG chlamydial antibody titers (less than or equal to 1:8 dilution), none of the patients had a 1:16 dilution, and 52 (82.5%) had positive IgG chlamydial antibody titers (greater than or equal to 1:32 dilution). Thus, chlamydial infections of the endocervix are rare and not commonly associated with poor PCTs in this patient population.

Microelectrode for measuring local cortical oxygen tension and blood flow in the same microareas of cat cortex.

The purpose of this study is to investigate the relationship between changes in cortical Po2 (bPo2) and cortical blood flow when inhalating different oxygen mixtures. Experiments were performed on 31 cats anaesthetized with N2O/O2 plus supplemental drugs for immobilization and analgesia. Cortical Po2 was measured by the polarographic method using 25 microns Pt electrode (coated) and a 250 micron Ag-AgCl2 indifferent electrode, especially designed to rest lightly on the cortex by means of coiled spring support. Using the same electrode but with opposite tip polarization; local cortical blood flow (lCoBF) was measured at the same site by the H2-clearance method. The change of bPo2 in going from FiO2 25% to FiO2 75% was measured at 58 different sites. (Table 2). At 25% FiO2 the mean bPo2 was 24 +/- 16 mm Hg, with a range from 4 to 92 mm Hg. With increased FiO2 to 75% local bPo2 responded quite differently at adjacent sites. At 75% FiO2 the mean bPo2 was 42.7 +/- 32 mm Hg with a range from 10 mm Hg to 198 mm Hg. The bPo2 and lCoBF were both measured at 44 of the 58 different sites. Cortical sites with a resting bPo2 greater than 30 mm Hg at 25% FiO2 had a lCBF = 57 +/- 12 ml/100g m; whereas sites with resting normoxic bPO2 less than 20 mm Hg had a mean ICoBF = 56 +/- 14 ml/100g min.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of regional cerebral blood flow in TIA patients with and without occlusion or stenosis of major vessels.

The purpose of this study is to compare the background regional cerebral blood flow (rCBF) in TIA patients with and without angiographically demonstrable lesions. 147 TIA patients with severe stenosis or occlusion of major vessels supplying the brain (A group) were compared with a similar group without any arterial lesion demonstrable by angiography (B group). Their rCBFs were measured by the intravenous Xe133 technique. The average of mean rCBF (MrCBF) in (A) group (119 cases) with a mean age of 59.9 yrs was 50.1 +/- 12.3 ml/100g/m and the average of MrCBF in (B) group (31 cases) with a mean age of 59.3 years was 47.6 +/- 11.8 ml/100g/m. In spite of no angiographic lesion in (B) group, the MrCBF was lower in value than that in (A) group. The average of hemispheric rCBF (HrCBF) was approximately the same bilaterally in a control group (55.4 ml/100g/m), and even in (B) group there was no significant difference between the symptomatic side and the non-symptomatic side. In (A) group, HrCBF on the symptomatic side (48.1 ml/100g/m) was significantly lower on the average than that on the opposite side (51.5 ml/100g/m). Comparing probe by probe in TIA patients, the average rCBF of the symptomatic site was 44.1 +/- 11.9 ml/100g/m and that of the symmetrically opposite site was 47.6 +/- 13.0 ml/100g/m in (A) group. In (B) group, the average rCBF of the symptomatic site was 46.2 +/- 10.8 ml/100g/m, and 47.7 +/- 10.8 ml/100g/m for the non-symptomatic site. These values in both group (A) and (B), have a significant difference between symptomatic probes and non-symptomatic probes (p less than 8.0 X 10(-7) and p less than 6.5 X 10(-3)).

Smaller subcortical volumes and cognitive deficits in children with prenatal methamphetamine exposure.

The purpose of this pilot study was to examine possible neurotoxic effects of prenatal methamphetamine (Meth) exposure on the developing brain and on cognition. Meth-exposed children (n=13) and unexposed control subjects (n=15) were evaluated with MRI. Global brain volumes and regional brain structures were quantified. Ten Meth-exposed and nine unexposed children also completed neurocognitive assessments. Meth-exposed children scored lower on measures of visual motor integration, attention, verbal memory and long-term spatial memory. There were no differences among the groups in motor skills, short delay spatial memory or measures of non-verbal intelligence. Despite comparable whole brain volumes in each group, the Meth-exposed children had smaller putamen bilaterally (-17.7%), smaller globus pallidus (left: -27%, right: 30%), smaller hippocampus volumes (left: -19%, right: -20%) and a trend for a smaller caudate bilaterally (-13%). The reduction in these brain structures correlated with poorer performance on sustained attention and delayed verbal memory. No group differences in volumes were noted in the thalamus, midbrain or the cerebellum. In summary, compared with the control group, children exposed to Meth prenatally exhibit smaller subcortical volumes and associated neurocognitive deficits. These preliminary findings suggest prenatal Meth exposure may be neurotoxic to the developing brain.

Effects of prenatal methamphetamine exposure on fetal growth and drug withdrawal symptoms in infants born at term.

To determine fetal growth and the incidence of withdrawal symptoms in term infants exposed to methamphetamine in utero, we retrospectively identified neonates whose mothers used methamphetamine during pregnancy and matched them to unexposed newborns. Exclusion criteria included multiple and preterm gestations. Although there were no differences in infant growth parameters between the methamphetamine-exposed and methamphetamine-unexposed neonates, methamphetamine exposure throughout gestation was associated with decreased growth relative to infants exposed only for the first two trimesters. In addition, there were significantly more small for gestational age infants in the methamphetamine group compared with the unexposed group. Methamphetamine-exposed infants whose mothers smoked had significantly decreased growth relative to infants exposed to methamphetamine alone. Withdrawal symptoms (as determined by a previously reported scoring system) requiring pharmacologic intervention were observed in 4% of methamphetamine-exposed infants. These preliminary findings indicate that methamphetamine use is associated with growth restriction in infants born at term.

Long-term evaluation of cerebral blood flow, transient ischemic attacks, and stroke after STA-MCA anastomosis.

A group of 107 consecutive patients with patent extracranial-intracranial bypasses were followed an average of 25.2 months to determine the long-term results on regional cerebral blood flow (rCBF), transient ischemic attacks (TIAs), and stroke incidence. Average mean rCBF initially rose to 110% at 1 week, then gradually fell to 105% at 6 months, and 85% at 2 years. Maximum increase in cerebral blood flow occurred in patients with middle cerebral artery stenosis or those in the preoperative low flow group, i.e., less than 50 ml/100 gm/min. In the group with TIAs plus mild stroke, the mean rCBF rose to 122% at 1 week, compared to the group with TIAs only who showed a mean increase to 107% at one week. Clinical improvement was excellent or good in 82% of those with TIAs only; in those with TIAs plus mild stroke, 77% had excellent or good relief of TIAs; and in those with mild stroke only, 70% recovered from their neurological deficits. In the 25.2 months of average follow-up, stroke occurred in only 1 patient on the side of the anastomosis, and in 2 patients on the side opposite the anastomosis, giving an average stroke incidence of 1.5% per year.